Organization
SHOPKO STORES OPERATING CO LLC
Active
Other names
Shopko Pharmacy 654
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MICHAEL BETTIGA RPH (EXECUTIVE VICE PRESIDENT & COO)
(920) 429-4297
Entity
Organization
Contact information
Practice address
2015 S DEFIANCE ST, ARCHBOLD, OH 43502-9111
(419) 445-0052
(419) 445-0053
Mailing address
2015 S DEFIANCE ST, ARCHBOLD, OH 43502-9111
(419) 445-0052
(419) 445-0053
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2183551
—
OH
01
—
3668069
NCPDP NUMBER
—
Enumeration date
05/17/2006
Last updated
10/22/2012
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